Marcia Angell’s two-part essay in the New York Review of Books, which appeared in the June and July issues, has helped trigger a much-needed societal discussion about the merits of psychiatric medications. Numerous web sites and bloggers have commented on her essay; personally, I have heard it discussed in my local gym, at my neighborhood coffee shop, and in other everyday settings.
Dr. Angell’s essay, which reviewed three books (one of which was mine, Anatomy of an Epidemic), raised fundamental questions about psychiatry’s diagnostics and its treatments. As could be expected, it stirred a response from leaders in American psychiatry. The New York Times provided Peter Kramer with an extraordinary forum—the front page of its Sunday Review section—to pen an essay “In Defense of Antidepressants.” Now, in the current issue of the New York Review of Books, there are a number of letters-to-the-editor from prominent psychiatrists, with a reply by Dr. Angell.
In a previous post, I wrote about how Dr. Kramer, in his defense of antidepressants, misrepresented the research findings by Irving Kirsch and Robert DeRubeis, and of course that is revealing in its own way. The letters published by the New York Review of Books are also quite revealing, and that is particularly true of two comments made by Richard Friedman and Andrew Nierenberg in their joint letter. Dr. Friedman is director of the psychopharmacology clinic at Weill Cornell Medical College, while Dr. Nierenberg is director of the bipolar clinic and research program at Massachusetts General Hospital.
Here are the two salient points.
A. The chemical imbalance theory of mental disorders is “outdated and disproven.”
In her essay, Dr. Angell noted that, after reviewing the three books, it appeared that there was little scientific merit to the chemical imbalance theory of mental disorders. In their letter, Friedman and Nierenberg criticize Angell for making it seem as though this is news: “Angell uses an outdated and disproven chemical imbalance theory of depression (i.e., serotonin deficiency) as a straw man to deny that depression has any biological basis at all.”
Now, as Dr. Angell notes in her able--and I must say, vigorous--reply, she didn’t write in her essay that depression doesn’t have a biological basis. She simply wrote that the chemical imbalance story didn’t appear to have merit. But forget about that back and forth, for here’s the critical point: In their letter, Dr. Friedman and Dr. Nierenberg acknowledged that the chemical imbalance theory of mental disorders was disproven long ago.
That, in fact, is true. But of course it begs a question. Why then has the American public regularly been told for the past two decades that psychiatric medications fix chemical imbalances in the brain, like “insulin for diabetes?” Why was it okay for the profession to tell society that false story?
This is a question, I think, that the psychiatric establishment should address, and as it does so, it needs to mull over this thought: Is it possible to imagine cardiologists or oncologists telling their patients that they have a known biological deficiency, which requires lifelong treatment, when research hadn’t shown that to be true?
B. The prevalence of mood disorders has not increased, but treatment of those disorders has.
In their letter, Dr. Friedman and Dr. Nierenberg make this argument: “What about the inflammatory claim that psychiatric drugs increase the rates of psychiatric disorders? If so, one would expect to see a steady increase in the prevalence of mental disorders in the population. But the epidemiologic evidence shows otherwise.”
Here, they are misstating the nature of the “mystery” I investigate in my book, Anatomy of an Epidemic. I ask this question: Why has the number of people on government disability due to mental illness soared in the past thirty years? Could psychiatric drugs be fueling that epidemic of people disabled by mental disorders? And the key point here is this: in their presentation of prevalence and treatment data, Dr. Friedman and Dr. Nierenberg have unwittingly provided compelling evidence that the drugs are doing just that.
In their letter, they note that the prevalence of anxiety, mood and substance disorders has been stable in the American population: 29.4% in 1991 and 30.5% in 2003. What went up during this period was the percentage of people receiving treatment, from 20 percent in 1991 to 32.7 percent in 2003.
Now, if psychiatric medications help people with mood disorders function well over the long term, then one would expect that as more people with a mood disorder got treated, then the number of people on government disability due to mental illness would decline (or at least stabilize.) However, if psychiatric medications increase the risk of long-term disability, then you would expect disability numbers to increase.
So let’s do the math. If you look up census data for the number of adults in 1990 and 2003, and then do the relevant prevalance-and-treatment calculations, you find that the number of people treated for mood disorders and substance abuse rose from 11.16 million adults in 1990 to 21.77 million in 2003. At the same time, the number of people receiving SSI or SSDI due to mental illness more than doubled, from 1.47 million people in 1990 to 3.25 million in 2003.
In short, as more people were treated for mood disorders, more people ended up disabled by mental illness. I wish that I had had this information when I wrote Anatomy of an Epidemic, for it provides information important for society to consider.
There is a third revealing point to be found in the letters-to-the-editor published by the New York Review of Books. In her essay, Dr. Angell questioned whether there was good evidence that psychiatric medications do more good than harm (particularly over the long term.) The obvious way for psychiatry to answer that question would be to cite studies that show that psychiatric medications improve the long-term course of major mental disorders. But none of the letter writers refer to any such long-term studies, and Dr. Angell, in her reply, points that out. “All three of these letters simply assume that psychoactive drugs are highly beneficial, but none of them provides references that would substantiate that belief,” she wrote. “Our differences stem from the fact that I make no such assumption.”
Her words here neatly focus on the issue that our society desperately needs to address. We have been using these drugs now for more than 50 years, and so one might expect that, after all this time, there would be good evidence that the medications are helpful over the long-term. But where is that evidence?